Interpretive policy analysis: Marshallese COFA migrants and the Affordable Care Act

McElfish et al. International Journal for Equity in Health (2016) 15:91 DOI 10.1186/s12939-016-0381-1 RESEARCH Open Access Interpretive policy analysis: Marshallese COFA migrants and the Affordable Care Act Pearl Anna McElfish1*, Rachel S. Purvis1, Gregory G. Maskarinec2, Williamina Ioanna Bing1, Christopher J. Jacob1, Mandy Ritok-Lakien1, Jellesen Rubon-Chutaro1, Sharlynn Lang1, Sammie Mamis1 and Sheldon Riklon2 Abstract Background: Since the enactment of the Affordable Care Act (ACA), the rate of uninsured in the United States has declined significantly. However, not all legal residents have benefited equally. As part of a community-based participatory research (CBPR) partnership with the Marshallese community, an interpretative policy analysis research project was conducted to document Marshallese Compact of Free Association (COFA) migrants’ understanding and experiences regarding the ACA and related health policies. This article is structured to allow the voice of Marshallese COFA migrants to explain their understanding and interpretation of the ACA and related polices on their health in their own words. Methods: Qualitative data was collected from 48 participants in five focus groups conducted at the local community center and three individual interviews for those unable to attend the focus groups. Marshallese community co-investigators participated throughout the research and writing process to ensure that cultural context and nuances in meaning were accurately captured and presented. Community co-investigators assisted with the development of the semi-structured interview guide, facilitated focus groups, and participated in qualitative data analysis. Results: Content analysis revealed six consistent themes across all focus groups and individual interviews that include: understanding, experiences, effect on health, relational/historical lenses, economic contribution, and pleas. Working with Marshallese community co-investigators, we selected quotations that most represented the participants’ collective experiences. The Marshallese view the ACA and their lack of coverage as part of the broader relationship between the Republic of the Marshall Islands (RMI) and the United States. The Marshallese state that they have honored the COFA relationship, and they believe the United States is failing to meet its obligations of care and support outlined in the COFA. Conclusion: While the ACA and Medicaid Expansion have reduced the national uninsured rate, Marshallese COFA migrants have not benefited equally from this policy. The lack of healthcare coverage for the Marshallese COFA migrants exacerbates the health disparities this underserved population faces. This article is an important contribution to researchers because it presents the Marshallese’s interpretation of the policy, which will help inform policy makers that are working to improve Marshallese COFA migrant health. Keywords: Health disparities, Community-based participatory research, Pacific Islanders, Health policy, Minority health Background The Marshallese population is rapidly expanding in the United States, having more than tripled between 2000 and 2010 [1]. The United States controlled the Republic of the Marshall Islands (RMI) as part of the Trust Territory of the Pacific Islands (TTPI) from 1947 to 1986. Upon the signing of the Compact of Free Association (COFA) * Correspondence: 1 Office of Community Health and Research, University of Arkansas for Medical Sciences Northwest, 1125 N. College Ave, Fayetteville, AR 72703, USA Full list of author information is available at the end of the article between the RMI and the United States in 1986, the RMI became a sovereign nation. The COFA allows Marshallese citizens to lawfully enter the United States, and to reside, work, and study without a visa or permanent resident card [2]. Based upon local health department and school records reported by the RMI consulate in personal communications with the lead investigator, an estimated 10,000 Marshallese people currently reside in Arkansas, the largest population of Marshallese living in the continental United States [3]. Beginning with only a few Marshallese migrants arriving in the late 1980s to work in the poultry © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. McElfish et al. International Journal for Equity in Health (2016) 15:91 industry in northwest Arkansas, the Marshallese community has grown steadily over the past three decades [4]. Compared with the general U.S. population, Marshallese migrants are typically younger, have less educational attainment, and higher rates of poverty [5]. The RMI was the principal site of the United States’ nuclear testing program from 1946 to 1958 [6, 7]. The burden of these nuclear tests were equivalent in payload to more than 7,000 Hiroshima-sized bombs, and the Marshall Islands are now considered to have the highest level of nuclear contamination in the world [7]. The nuclear tests destroyed entire atolls in the island chain and contaminated the plant and sea life of many other islands [7–10]. The nuclear explosions, subsequent contamination of the Marshall Islands, and the relocation of Marshall Islanders permanently altered the traditional diet and lifestyle of the Marshallese, and the resulting changes in their diet has serious health effects [7, 11–14]. The Marshallese population living in the RMI and the United States face significant health disparities [15–18]. Rates of diabetes are documented at more than 400 % the national average [19]. Infectious diseases, particularly hepatitis B, tuberculosis (TB), and Hansen’s disease (leprosy) are also found at higher rates among the Marshallese than in the general population [20–27]. In addition, Marshallese mothers in the United States give birth to low birth weight babies at higher rates than the general U.S. population [28]. Health care reform policy and its impact on Marshallese health The Patient Protection and Affordable Care Act (ACA) was signed into law by President Obama in March 2010 and later upheld by the Supreme Court in June 2015 [29]. The law creates marketplaces where consumers can purchase subsidized health insurance, and it also requires legal residents to obtain health insurance [30]. The ACA offers states the option to expand Medicaid to more low-income (133 % of poverty level) residents. Arkansas is one of 29 states that expanded Medicaid to low- (...truncated)